Published: 30/09/2004, Volume II4, No. 5925 Page 30 31

Cornwall can't splash out on community services while it is saddled with a£35m deficit, but the reimbursement strategy for delayed discharge has opened up a casket of financial opportunities, as Colleen Shannon explains

Like all health economies in the UK, Cornwall is working to modernise community services, especially for the elderly. But in the cash-strapped county the work ahead is much like making Cinderella's ball gown: the pattern is there, but stitching it all together will require thrift and clever needlework.

The figures certainly suggest that some nips and tucks are needed. The annual rate of emergency admissions to hospital is 133.2 per 1,000 population in Cornwall, compared to a national average of 109.6. Acute beds account for 47 per cent of spending, versus 43 per cent nationally.Managers here talk about chronic underinvestment in community services and a historical over-reliance on hospital beds.

At one of Cornwall's primary care trusts, a public consultation has just ended on plans to address these problems by redesigning services. Proposals include closing one in four beds in the PCT's community hospitals to allow reinvestment in other models of care.

'It is about getting the balance right between having a number of local beds but then [providing] a range of specialist chronic-disease management services that can start to turn around this dependency we have on emergency admissions, ' says Central Cornwall PCT director of operational services Carol Williams.

Financially, the starting point can only be described as 'very difficult', says Ms Williams. The Cornish health community is in the midst of a two-year financial recovery plan. An inherited deficit of£35m is shared across the patch. The challenge, therefore, is to redesign community services within existing revenue levels.

Part of the solution has been to work with other PCTs, the acute Royal Cornwall Hospitals trust and social services to make creative use of the Department of Health's reimbursement strategy for delayed discharge.

Under this scheme, if a patient's discharge from hospital is delayed solely because supporting community care arrangements are lacking, the local authority must financially reimburse the acute trust.

In Cornwall, these funds are expected to total around£2m over the next two years. By local agreement, this money is being used to build up capacity in the community. Some of the schemes include:

Rapid response assessment teams. These multidisciplinary teams provide community nursing, therapy and social service packages of care to prevent emergency admissions and facilitate early hospital discharge.

EPIC nurses (Eldercare Project in Cornwall). These nurses are placed in GP practices with the highest repeat emergency admission rates for over-75s, and work to the Evercare model of preventive care and chronic-disease management.

Physiotherapy and occupational therapy expansion.

More capacity in the acute trust facilitates direct discharge.

Acute care at home. Patients with heart failure and chest infections can be treated at home. Blood transfusions and some intravenous antibiotics can be provided.

These programmes are new but some are already providing demonstrable benefits, says Ms Williams. In its first four weeks, the rapid assessment team took 100 referrals and prevented 80 admissions.

Another encouraging sign is a decline in the bed occupancy rate for the PCT's community hospitals, which has fallen below 90 per cent for the first time. The rate of emergency admissions by GPs has stopped its steady climb.

Central Cornwall PCT has community hospitals in St Austell, Fowey, Falmouth and Newquay, with a total of 140 beds and a history of fierce loyalty from local people. In 1998, plans to close Fowey Hospital, along with hospitals in other parts of Cornwall, were met with candlelit vigils and protest marches. Then health secretary Frank Dobson intervened to ensure they remained open.

To keep such services running over the longer term and to provide updated facilities, the PCT wants to redirect funding by closing beds in three of its four community hospitals (see table).Money saved will be invested in services such as chronic-disease management, services for the elderly and minor illness units.

Today, Central Cornwall PCT remains convinced that Fowey Community Hospital is not fit for purpose and therefore the most radical changes are proposed for this site. The PCT wants to raze the old building and build a new community facility with the private sector.

There would be a reduced number of NHS beds, with the addition of new dementia beds commissioned by social services, and nursing home beds provided by the private sector. Ideally, the centre would also house local GPs, dentists and a community pharmacy, as well as a nursery providing childcare.

The minor injury unit would be closed for efficiency reasons. The nurse-led unit treats 900 patients per year, compared to 13,000 at St Austell Community Hospital six miles down the road.

This time there has been extensive public consultation but no protest march. For the most part the response has been one of 'resounding apathy', says David Whalley, a county councillor and chair of Cornwall county council's oversight and scrutiny committee. The PCT has held more than a dozen public meetings and many were poorly attended. 'It could be that the plans are perceived as sensible and people have not felt driven to attend a meeting, ' he suggests.

The one exception is Fowey, where public concern has been considerable and meetings have been crowded. 'At the last meeting I attended I think the PCT had largely allayed those fears, ' says Mr Whalley.

Patient representatives think the proposals sound sensible overall. 'I can see that they have made a good stab at trying to make sure the services they're going to provide are fit for purpose, ' says PCT patient forum vice-chair Barbara Hewett-Silk. 'It does seem that it will be a better service.Making the public feel secure in that is quite difficult.'

'The PCT has set up an admirable consultation process, ' adds Mr Whalley. 'This needs to be the beginning of a much longer-term engagement with the population, because the PCT has only been asking for broad approval.'

For its part the local medical committee broadly welcomes the work. Chair Dr Philip Dommett says: 'While it would be better to have the same number of beds and additional services, we have to be realistic.We would like assurances that patients who need a community hospital bed will still be able to access one.'

Key points

Central Cornwall PCT suffers from a historical under-investment in community services.

Fines related to delayed discharge will bring in£2m, which will help build up community capacity.

A reorganisation of community hospitals is being planned.

Further information

Central Cornwall PCT website, www. cornwall. nhs. uk/centralpct/index. asp